AUGUST 200 JULY Reauthorization of PEPFAR, The United States Leadership Against HIV/AIDS, Tuberculosis and Malaria Act:

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1 Reauthorization of PEPFAR, The United States Leadership Against HIV/AIDS, Tuberculosis and Malaria Act: JULY 2008 AUGUST 200 A Side-by-Side Comparison to Current Law

2 Reauthorization of PEPFAR, The United States Leadership Against HIV/AIDS, Tuberculosis and Malaria Act: A Side-by-Side Comparison to Current Law The United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 (Leadership Act), also known as the President s Emergency Plan for AIDS Relief (PEPFAR), was first enacted in PEPFAR authorized up to $15 billion over five years to address HIV/AIDS, tuberculosis and malaria in low- and middle-income countries through bilateral assistance and contributions to the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund). Due to be reauthorized this year, the United States Congress passed a bipartisan, five-year reauthorization bill, The Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008, on July 24, 2008, which was signed into law by the President on July 30, The following table, prepared by the Kaiser Family Foundation, provides a side-by-side comparison of the newly reauthorized bill to prior law. Key Documents Used and Other Suggested Resources: U.S. Congress, 110 th Congress, 2 nd Session, H.R Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008 (Enrolled as Agreed to or Passed by Both House and Senate); July 24, Congressional Research Service. International HIV/AIDS, Tuberculosis, and Malaria: Key Changes to U.S. Programs and Funding. RL34569; July The United States President s Emergency Plan for AIDS Relief: President s Malaria Initiative: The Global Fund to Fight AIDS, Tuberculosis and Malaria: Kaiser Family Foundation. Fact Sheet: U.S. Federal Funding for HIV/AIDS: The FY 2009 Budget Request; April 2008: Kaiser Family Foundation. Financing the Response to AIDS in Low- and Middle- Income Countries: International Assistance from the G8, European Commission and Other Donor Governments, 2007; July 2008: Center for Strategic and International Studies, Task Force on HIV/AIDS: Page 1 of 6

3 P.L Title United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008 Enacted May 27, 2003 July 30, 2008 Funding Authorization Period / Amount Spending Directives FY 2004 FY 2008 $15 billion ($3 billion/year) $1 billion for Global Fund in FY 2004 (and such sums as necessary FY ) Recommends (sense of Congress): 20% of funds be spent on prevention 15% of funds be spent on palliative care Requires (for FY ): at least 55% be spent on treatment; at least 10% be spent on orphans and vulnerable children; At least 33% of appropriated prevention funds be spent on abstinence-until-marriage programs. FY 2009 FY 2013: $48 Billion (in total) $2 billion for Global Fund in FY 2009 (and such sums as necessary FY ) $4 billion for Tuberculosis (in total) $5 billion for Malaria (in total) (also authorizes $2 billion for Emergency plan for Indian safety and health) Requires: At least 10% be spent on orphans and vulnerable children; Half of bilateral aid be spent on AIDS treatment and care Balanced funding for prevention activities for sexual transmission of HIV/AIDS, and that activities promoting abstinence, delay of sexual debut, monogamy, fidelity, and partner reduction are implemented and funded in a meaningful and equitable way in the strategy for each host country A report to Congress if less than half of prevention funds go to abstinence, delay of sexual debut, monogamy, fidelity, and partner reduction in any host country with a generalized epidemic Removes: 33% abstinence-until-marriage directive Page 2 of 6

4 Targets/Goals Global Fund to Fight AIDS, Tuberculosis & Malaria Focus Countries/Regions Program Coordinator Immigration and Travel Ban of HIV Positive Individuals P.L Prevent 7 million new HIV infections; Treat 2 million people with HIV/AIDS; Care for 10 million people infected and affected by HIV/AIDS, including orphans and vulnerable children Authorization of up to $1 billion in FY 2004 and such sums as necessary for FY /3 cap on U.S. contribution to Global Fund (cannot exceed 33% of contributions from all sources) Designates 14 countries as focus countries: Botswana, Cote d Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Zambia Vietnam later designated as focus country by President as matter of policy Establishes Global HIV/AIDS Coordinator at Department of State with oversight of all USG programs and resources for combating HIV/AIDS Not referenced in PEPFAR; was governed by Immigration & Nationality Act which prohibits HIV-positive individuals from visiting or immigrating to the United States (except if a waiver is granted). HIV is only health condition specifically named as inadmissible in the law; for all others, the Secretary of Health and Human Services is given the authority to decide what conditions pose public health threats Prevent 12 million new HIV infections; Provide treatment to more than 2 million people with HIV/AIDS (original PEPFAR 2003 target) by at least the percentage increase in the amount appropriated for bilateral global HIV/AIDS assistance in any FY as compared to FY 2008; treatment goal to be increased above this calculated number in proportion to the decrease in the per patient cost to the United States Government of providing treatment in countries receiving bilateral aid, as compared with fiscal year 2008; Care for 12 million, including 5 million orphans and vulnerable children Help partner countries reach PMTCT coverage target of at least 80% of pregnant women in affected countries Help partner countries provide care and treatment to children with HIV/AIDS in proportion to their share of the HIV-infected population in country Help partner countries train at least 140,000 new health workers Equip teachers with skills needed to address HIV Authorization doubled from up to $1 billion in FY 2004 (and such sums as necessary FY ) to up to $2 billion in FY 2009, and such sums as necessary FY Retains 1/3 cap on U.S. contribution Includes provision which would allow for withholding 20% of annual contribution pending certification to certain accountability and transparency benchmarks Adds Vietnam as focus country Adds Central Asia, Eastern Europe, and Latin America, in addition to Sub Saharan Africa and the Caribbean, as regions of importance for provision of foreign assistance Adds Malaria Coordinator at USAID, with oversight of all USG programs and resources for combating malaria Ends statutory prohibition against HIV-positive visitors and immigrants by amending the Immigration & Nationality Act to strike clause which shall include infection with the etiologic agent for acquired immune deficiency syndrome ; returns decision about whether HIV should be considered a threat to public health to the Secretary of Health & Human Services, as is the case for all other health conditions Page 3 of 6

5 Prevention and Abstinence-Until-Marriage Directive Family Planning Prostitution Pledge P.L Recommends (Sense of Congress) that 20% of bilateral assistance be spent on prevention Requires that 33% of funds appropriated for prevention be spent on abstinence-until-marriage programs Requires that prevention activities supported are designed or intended to impart knowledge with the exclusive purpose of helping individuals avoid behaviors that place them at risk of HIV infection, including integration of such programs into health programs and the inclusion in counseling programs of information on methods of avoiding infection of HIV, including delaying sexual debut, abstinence, fidelity and monogamy, reduction of casual sexual partnering, reducing sexual violence and coercion, including child marriage, widow inheritance, and polygamy, and where appropriate, use of condoms Mexico City exemption to allow family planning groups to receive PEPFAR funds for HIV services only Organizations must have policy opposing prostitution to be eligible for funding Requires: Balanced Funding for prevention activities for sexual transmission of HIV/AIDS; and that activities promoting abstinence, delay of sexual debut, monogamy, fidelity, and partner reduction are implemented and funded in a meaningful and equitable way in the strategy for each host country A report to Congress if less than half of prevention funds in any host country go to abstinence, delay of sexual debut, monogamy, fidelity, and partner reduction. Funds used for new prevention technologies/modalities excepted from balanced funding requirement Removes: 33% requirement for prevention funds Adds: Authority for microbicides research at the National Institutes of Health and Centers for Disease Control and Prevention Male circumcision as a prevention method Addressing multiple concurrent sexual partnering as supported prevention activity That supported activities include female and male condoms (change from condoms in PEPFAR 2003) Maintains current law (family planning not mentioned) Maintains current law and includes language stating that no funds to provide assistance to any group or organization that does not have a policy explicitly opposing prostitution and sex trafficking Page 4 of 6

6 Gender/Women & Girls Health Systems/ Workforce Food & Nutrition Partnerships or Compacts with Recipient Countries P.L Gender not mentioned Requires PEPFAR strategy to specifically address needs and vulnerability of women and girls Requires reporting of indicators related to reaching women and girls in annual reports PMTCT emphasized and annual reports on PMTCT required; includes target of meeting or exceeding the goal to reduce the rate of mother-to-child transmission of HIV by 20 percent by 2005 and by 50 percent by 2010 Mentioned briefly; not major focus Support for food and nutrition assistance given as Sense of Congress N/A Addressing multiple concurrent sexual partnering as supported prevention activity Includes greater emphasis and more explicit emphasis on women and girls, particularly related to PMTCT and families, and adds language about gender and genderrelated vulnerabilities to HIV. Changes subtitle B of legislation from Assistance for Children and Families to Assistance for Women, Children and Families with target of 80% coverage for PMTCT, annual report on PMTCT, and establishment of PMTCT expert panel Specifically requires that global HIV/AIDS prevention strategy address vulnerabilities of women and youth to HIV infection, and seek to reduce factors that lead to gender disparities in HIV Adds more detailed accountability measures on reaching women and girls and gender-specific accountability measures Requires IOM to include assessment of efforts to address gender-specific aspects of HIV/AIDS, including gender related constraints to accessing services and addressing underlying social and economic vulnerabilities of women and men, in its evaluation Includes sense of Congress concerning need and urgency of expanding range of female-controlled HIV prevention Includes significantly greater emphasis on health workforce training and capacity building, with specific workforce target (training at least 140,000 new health workers) Support for food and nutrition assistance strengthened; more strongly authorizes use of assistance for purchase of food as a component of treatment; requires nutritional assessments in all HIV programs Adds compacts and framework agreements with recipient countries to promote host government commitment to deeper integration of HIV/AIDS services into health systems, contribute to health systems overall, enhance sustainability Page 5 of 6

7 Tuberculosis Malaria Advanced Market Commitments (AMCs) Institute of Medicine (IOM) Study and Other Required Evaluations and Research P.L Control of tuberculosis (TB) cited as major objective of the foreign assistance program of the United States ; priority given to Directly Observed Treatment Short-course (DOTS) No bilateral funding authorization is specified (President authorized to determine) but requirement that at least 75 percent of the amount made available for TB each year must be spent on drugs, supplies, direct patient services, DOTS training, treatment of multi-drug resistant tuberculosis using DOTS-Plus, including substantially increased funding for the Global Tuberculosis Drug Facility Support for TB also provided through USG contributions to Global Fund Prevention, control, and cure of malaria cited as major objective of the foreign assistance program of the United States. No bilateral funding authorization is specified (President authorized to determine) Support for malaria also provided through USG contributions to Global Fund N/A IOM study required Authorizes $4 billion over 5 years Significantly strengthens and elevates focus on TB. Adds specific TB goals Requires 5-year TB strategy Authorizes $5 billion over 5 years Adds Malaria Coordinator at USAID, with oversight of all USG programs and resources for combating malaria Strengthens, embraces President s Malaria Initiative. Requires 5-year malaria strategy Requires the United States to participate in negotiations for advance market commitments for the development of future vaccines IOM studies required for: data evaluation plan; performance assessment; impact evaluation Requires Best Practices Report Requires Comptroller General Report Page 6 of 6

8 Additional copies of this publication (#7799) are available on the Kaiser Family Foundation s website at The Kaiser Family Foundation is a non-profit private operating foundation dedicated to producing and communicating the best possible information and policy analysis on health issues. The Henry J. Kaiser Family Foundation Headquarters: 2400 Sand Hill Road, Menlo Park, CA USA Phone: Fax: Washington Offices and Barbara Jordan Conference Center 1330 G Street, NW, Washington, DC USA Phone: Fax: